Healthcare Provider Details

I. General information

NPI: 1659866614
Provider Name (Legal Business Name): JESSICA NELSON MHA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2018
Last Update Date: 05/05/2026
Certification Date: 05/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2025 CORPORATE DR STE 3
RICHMOND KY
40475-6535
US

IV. Provider business mailing address

2293 MARKET GARDEN LN
LEXINGTON KY
40509-8525
US

V. Phone/Fax

Practice location:
  • Phone: 859-248-6508
  • Fax:
Mailing address:
  • Phone: 859-351-9181
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number299992
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number299654
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: